Case Presentation:
A 73 year old male with history of indolent marginal cell lymphoma and splenectomy admitted to an outside hospital with generalized malaise and jaundice. History included DM, HTN, prior enterococcal endocarditis and streptococcal meningitis.
He was transferred for a hematocrit drop from 32 to 17 without a bleeding source. On presentation, he was a mildly lethargic male with diarrhea, jaundice, skin itching, and generalized weakness. Temperature was 101 F, Pulse 90, B/P 140/90, RR 16. Oropharynx was dry. JVP was 5. Lungs showed bibasilar decreased breath sounds associated with percussion dullness. Cardiac, abdominal and neurological exams were unrevealing. Skin was pruritic without rash. Laboratory studies showed macrocytic anemia with 1+ schistocytes. LDH, indirect bilirubin and reticulocytosis confirmed hemolysis. Liver transaminases were mildly elevated. Band count elevated to 30% of 9000 WBCs with toxic granulations and dohle bodies. Consecutive DIC panels ruled out DIC. Bacterial blood and urine cultures were negative. Chest CT showed bilateral pleural effusions but no pulmonary infiltrate. Thoracentesis revealed exudate without organisms or bacterial growth. Cells were atypical, but flow did not show evidence of lymphoma. Piperacillin Tazobactam, Azithromycin and Vancomycin were started and symptoms and labs normalized over days. All cultures and lumbar puncture results were unrevealing. Cold agglutinins were negative, but Anti‐I on RBC was positive, diagnostic for cold agglutinin associated hemolysis. Mycoplasma pneumoniae IgM titer was 2049 u/mL (negative <770), while IgG was negative, confirming acute Mycoplasma pneumoniae infection presenting with primarily extra pulmonary manifestations.
Discussion:
Mycoplasma pneumoniae most commonly presents as atypical pneumonia, with or without extra pulmonary manifestations. This patient did not show any signs of pneumonia, but manifested profound hemolysis, fever, lethargy, skin itching, nausea, vomiting, diarrhea and mild transaminitis, initially making the clinical diagnosis more difficult.
Another unusual aspect of this case is the degree of anemia, which is typically mild, not requiring transfusion. This patient did require transfusion before the diagnosis was recognized and treated.
The differential for anti Ig I or i, Coomb's positive anemia includes infection (mycoplasma, listeria, EBV) and malignancy (lymphomas and leukemias, indolent or aggressive). All of these were a possibility in this case, but the diagnosis was clear based on response to treatment and the Mycoplasma antibody titer.
Conclusion:
This is a demonstration of acute extra pulmonary manifestation of Mycoplasma pneumoniae infection requiring inpatient management. Although much rarer in general medical practice, this presentation is much more likely to be seen in inpatient care.
Author Disclosure Block:
D.C. Sliwka, None.